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Free Georgia Citizenship Affidavit Form - PDF Form Download

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Use this template/form as a Citizenship Affidavit Form in the State of Georgia

georgia-citizenship-affidavit-form


Text version of this Form

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OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334

ENFORCEMENT

www.oci.ga.gov Illegal Immigration Reform And Enforcement Act GID-276-EN AUG2012

Notice (replaces GID-235-SF)

In accordance with O.C.G.A. § 50-36-1, the Office of Insurance and Safety Fire Commissioner is required to verify

the lawful presence of all new and renewal applicants. Therefore, the following documents must be included

with every application submitted to this Office:

1. A signed and notarized copy of the attached Citizenship Affidavit Form; and

2. A copy of the front AND back of one secure and verifiable identification document. (Attached is a list of

ALL secure and verifiable documents that this Office can accept in order to satisfy this requirement. We

cannot accept any documents that are not included in this list. These documents may be submitted to this

Office electronically.)

All applicants are required to submit LEGIBLE COPIES of these two (2) documents before an application

can be processed. If applying on behalf of a business entity, then an employee or officer of the business entity, who

has authority, must complete and submit these documents.

In addition, if you (or, for a business entity, the employer or officer with authority) are not a United States citizen,

we are required by law to verify your immigration status through the Federal Systematic Alien Verification of

Entitlement (SAVE) program.

MAILING INSTRUCTIONS

Submit the two (2) required documents referenced above with your complete application to the email address (if

submitted digitally) OR to the mailing address (if submitted in paper form) specified in the application instructions.

HOW TO FILL OUT THE CITIZENSHIP AFFIDAVIT FORM

Spaces #1 – #3 – Applicant should put an X in the space that best describes the applicant’s citizenship status. Please

note that applicant should put an X in ONLY ONE of these spaces.

• If you put an X in Space #2 (legal permanent resident) OR Space #3 (qualified alien or non-

immigrant), then applicant MUST write down the alien number that was issued by the

Department of Homeland Security or other federal immigration agency in the space provided.

Spaces #4 – #5 – Applicant should fill in the city and state in which this affidavit form is being notarized.

AN APPLICATION CANNOT BE PROCESSED IF THE CITIZENSHIP AFFIDAVIT FORM IS NOT

COMPLETELY FILLED OUT.

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this Affidavit

document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 – Phone 404-656-2056. Notice

———————– Page 2———————–

OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334

ENFORCEMENT

www.oci.ga.gov Illegal Immigration Reform And Enforcement Act GID-276-EN AUG2012

Citizenship Affidavit Form (replaces GID-235-SF)

If you know one of the following identifiers, please enter it here:

License # NAIC # Employer ID #

O.C.G.A. §50-36-1(e)(2) Affidavit

By executing this affidavit under oath, as an applicant for a license, certificate, registration,

permit, etc., as referenced in O.C.G.A. §50-36-1, from the Office of Insurance, Safety Fire and

Industrial Loan Commissioner, the undersigned applicant verifies one of the following with

respect to my application for a public benefit:

[Check ONLY ONE of the following:]

1) _________ I am a United States citizen; OR

2) _________ I am a legal permanent resident of the United States; OR

My alien number issued by the Department of Homeland Security or

other federal immigration agency is:___________________________.

3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and

Nationality Act with an alien number issued by the Department of Homeland

Security or other federal immigration agency.

My alien number issued by the Department of Homeland Security or

other federal immigration agency is:___________________________.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and

has provided at least one secure and verifiable document, as required by O.C.G.A.

§50-36-1(e)(1), with this affidavit.

In making the above representation under oath, I understand that any person who knowingly and

willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be

guilty of a violation of O.C.G.A. §16-10-20, and face criminal penalties as allowed by such

criminal statute.

Executed in ___________________ (city), __________________(state).

____________________________________

Signature of Applicant

____________________________________

SUBSCRIBED AND SWORN Printed Name of Applicant

BEFORE ME ON THIS THE

___ DAY OF ___________, 20___

_____________________________

NOTARY PUBLIC

My Commission Expires:

SUBMIT ONLY THIS COMPLETED CITIZEN AFFIDAVIT PAGE WITH THE REQUIRED DOCUMENTATION

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this Citizenship

document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 – Phone 404-656-2056. Affidavit

———————– Page 3———————–

OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334

ENFORCEMENT

www.oci.ga.gov Illegal Immigration Reform And Enforcement Act GID-276-EN AUG2012

Citizenship Affidavit Form (replaces GID-235-SF)

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot

later than August 1, 2011, the Attorney General shall provide and make public on the

Department of Law’s website a list of acceptable secure and verifiable documents. The list shall

be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The

Attorney General may modify this list on a more frequent basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A.

§ 50-36-2, contains documents that are verifiable for identification purposes, and documents on

this list may not necessarily be indicative of residency or immigration status.

• A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A driver’s license issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas

Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided

that it contains a photograph of the bearer or lists sufficient identifying information

regarding the bearer, such as name, date of birth, gender, height, eye color, and address to

enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• An identification card issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas

Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided

that it contains a photograph of the bearer or lists sufficient identifying information

regarding the bearer, such as name, date of birth, gender, height, eye color, and address to

enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A tribal identification card of a federally recognized Native American tribe, provided that

it contains a photograph of the bearer or lists sufficient identifying information regarding

the bearer, such as name, date of birth, gender, height, eye color, and address to enable

the identification of the bearer. A listing of federally recognized Native American tribes

may be found at:

http ://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/ind

ex.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A.

§ 50-36-2(b)(3); 8 CFR § 274a.2]

• An Employment Authorization Document that contains a photograph of the bearer

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this Citizenship

document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 – Phone 404-656-2056. Affidavit

———————– Page 4———————–

OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334

ENFORCEMENT

www.oci.ga.gov Illegal Immigration Reform And Enforcement Act GID-276-EN AUG2012

Citizenship Affidavit Form (replaces GID-235-SF)

• A Merchant Mariner Document or Merchant Mariner Credential issued by the United

States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

• A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

• A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A.

§ 50-36-2(b)(3); 22 CFR § 41.2]

• A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3);

8 CFR § 274a.2]

• A Certificate of Citizenship issued by the United States Department of Citizenship and

Immigration Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3);

6 CFR § 37.11]

• A Certificate of Naturalization issued by the United States Department of Citizenship and

Immigration Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3);

6 CFR § 37.11]

• In addition to the documents listed herein, if, in administering a public benefit or

program, an agency is required by federal law to accept a document or other form of

identification for proof of or documentation of identity, that document or other form of

identification will be deemed a secure and verifiable document solely for that particular

program or administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this Citizenship

document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 – Phone 404-656-2056. Affidavit

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